INTRODUCTION 1 PLAN ADMINISTRATION 3

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2 INTRODUCTION 1 PLAN ADMINISTRATION 3 ELIGIBILITY 3 ELIGIBLE DEPENDENTS 3 ELECTIONS AND ENROLLMENT PERIODS 5 COVERAGE OPTIONS 6 HEALTH CARE PREMIUMS 7 ID CARDS 7 WHEN HEALTH CARE COVERAGE ENDS 8 CONTINUING COVERAGE AFTER THE DEATH OF A RETIREE 9 QUALIFIED CHANGE EVENTS 9 CHANGE IN ADDRESS 11 BENEFICIARY INFORMATION 11 MEDICARE ELIGIBILITY AND THE VALERO RETIREE HEALTH CARE PLANS 11 QUALIFIED MEDICAL CHILD SUPPORT ORDERS (QMCSOS) 12 VALERO SPONSORED RETIREE HEALTH CARE PLANS 13 VALERO SPONSORED NON-MEDICARE PLANS 13 DEDUCTIBLE PLAN 13 DEDUCTIBLE PLAN SCHEDULE OF BENEFITS 13 PPO PLAN 14 PPO PLAN ROUTINE HEARING BENEFIT 15 PPO PLAN SCHEDULE OF BENEFITS 15 HOW THE DEDUCTIBLE AND PPO PLANS WORK 16 i

3 HOW MEDICAL EXPENSES ARE PAID THROUGH THE DEDUCTIBLE AND PPO PLANS 24 WHAT IS COVERED UNDER THE DEDUCTIBLE PLAN AND PPO PLAN 25 WHAT IS NOT COVERED UNDER THE DEDUCTIBLE PLAN AND PPO PLAN 60 AETNA RETIREE OUT-OF-AREA PLAN (OOA PLAN) 78 AETNA DEFINITIONS 79 COORDINATION OF BENEFITS FOR THE AETNA RETIREE MEDICAL PLANS 103 AETNA CLAIMS AND APPEALS 106 GROUP HEALTH CLAIMS 108 EXPRESS SCRIPTS TRADITIONAL PRESCRIPTION DRUG COVERAGE 111 PRESCRIPTION DEDUCTIBLE 111 RETAIL PHARMACY PRESCRIPTION 111 RETAIL90 MAINTENANCE DRUG PROGRAM (MDP) 111 MAIL ORDER 112 SMOKING CESSATION 112 STEP THERAPY 112 GLUCOSE MONITORS 112 PRIOR AUTHORIZATION 113 HOW TO USE THE PRESCRIPTION BENEFITS 113 PREFERRED DRUGS 114 ACCREDO SPECIALTY PROGRAM 114 WHAT THE PRESCRIPTION BENEFIT DOES NOT COVER 115 SCHEDULE OF BENEFITS 116 VALERO SPONSORED MEDICARE SUPPLEMENT PLANS 117 AETNA RETIREE DENTAL $50 DEDUCTIBLE PLAN 118 ii

4 HIGHLIGHTS 118 HOW THE DENTAL PLAN WORKS 118 WHAT THE DENTAL PLAN PAYS FOR 120 RULES AND LIMITS 128 WHAT THE DENTAL PLAN DOES NOT PAY FOR 129 SCHEDULE OF BENEFITS 133 AETNA DEFINITIONS 133 COORDINATION OF BENEFITS 133 CLAIMS AND APPEALS 136 VSP RETIREE VISION PLAN 137 HIGHLIGHTS 137 SCHEDULE OF BENEFITS 137 HOW VSP WORKS 138 EXTRA COST 139 WHAT VSP DOES NOT PAY FOR 140 WHEN VISION COVERAGE BEGINS AND ENDS 140 CLAIMS AND APPEALS 140 LIFE INSURANCE 146 IMPUTED INCOME 146 LIFE INSURANCE CLAIMS 146 PLAN INFORMATION 148 INFORMATION APPLICABLE TO ALL PLANS 148 HOW TO FILE A CLAIM 148 RIGHTS UNDER ERISA 148 iii

5 THE RIGHT TO RECEIVE INFORMATION ABOUT PLANS AND BENEFITS 148 THE RIGHT TO CONTINUE GROUP HEALTH CARE PLAN COVERAGE 149 THE RIGHT TO PRUDENT ACTIONS BY PLAN FIDUCIARIES 149 THE RIGHT TO ENFORCE ERISA RIGHTS 149 THE RIGHT TO RECEIVE ASSISTANCE WITH QUESTIONS 150 GENERAL INFORMATION 151 THE RIGHT TO RELEASE OR OBTAIN INFORMATION 152 CONSOLIDATED OMNIBUS BUDGET RECONCILIATION ACT OF 1985 (COBRA) 153 WHAT IS CONTINUATION COVERAGE? 153 OBLIGATION TO NOTIFY THE COBRA ADMINISTRATOR OF A QUALIFIED CHANGE EVENT 154 HOW LONG WILL CONTINUATION COVERAGE LAST? 154 HOW CAN YOU EXTEND THE LENGTH OF COBRA CONTINUATION COVERAGE? 155 HOW CAN YOU ELECT COBRA CONTINUATION COVERAGE? 155 ELECTION PERIOD 156 HOW MUCH DOES COBRA CONTINUATION COVERAGE COST? 156 WHEN AND HOW MUST PAYMENT FOR COBRA CONTINUATION COVERAGE BE MADE? 156 FOR MORE INFORMATION 158 KEEP YOUR PLAN INFORMED OF ADDRESS CHANGES 158 PAPERWORK REDUCTION ACT STATEMENT 158 HIPAA RIGHTS 160 HIPAA PRE-EXISTING CONDITIONS LIMITATIONS 160 HIPAA SPECIAL ENROLLMENT RIGHTS 160 iv

6 USE AND DISCLOSURE OF HEALTH INFORMATION 161 THE RIGHT OF SUBROGATION AND REIMBURSEMENT 162 LEGAL NOTICES 163 HIPAA PRIVACY NOTICE 163 THE NEWBORNS AND MOTHERS HEALTH PROTECTION ACT OF THE WOMEN S HEALTH AND CANCER RIGHTS ACT OF THE CHILDREN'S HEALTH INSURANCE PROGRAM REAUTHORIZATION ACT (CHIPRA), EFFECTIVE APRIL 1, THE GENETIC INFORMATION NONDISCRIMINATION ACT OF 2008 (GINA), EFFECTIVE JANUARY 1, THE MENTAL HEALTH PARITY AND ADDICTION EQUITY ACT, EFFECTIVE JANUARY 1, PATIENT PROTECTION AND AFFORDABLE CARE ACT (PPACA), EFFECTIVE MARCH 23, GOVERNING DOCUMENTS 169 AMENDMENT AND TERMINATION 170 PLAN ADMINISTRATION AND FUNDING 171 VALERO ENERGY CORPORATION RETIREE HEALTH CARE PLAN 171 ACRONYM INDEX 173 EXHIBIT A 176 EXHIBIT B 177 EXHIBIT C 178 EXHIBIT D 179 EXHIBIT E 180 v

7 EXHIBIT F 181 vi

8 INTRODUCTION This Valero Retiree Health and Welfare Benefits Handbook (handbook), which is considered the Summary Plan Description (SPD), summarizes the health and welfare benefits available to retirees and their covered dependents. The benefits and policies stated in this handbook are intended to provide sufficient information to explain all benefits and any exceptions or conditions to such benefits and policies. As such, please take time in reading each section as well as any cross references indicated. The benefits and policies stated in this handbook are subject to change at Valero's sole discretion. Valero Energy Corporation (the Plan Sponsor or Company ), as the Plan Sponsor, reserves the right to modify or terminate benefits at any time. When policy, benefit or premium changes are made, updated information will be distributed to retirees. While this handbook includes summaries of the health and welfare benefit plans, the contents of this handbook may not address all benefits in detail. This handbook does not replace the official plan documents or insurance contracts and policies that govern the plans provisions. In the event of a discrepancy, the terms of the official plan documents will prevail. The welfare benefit summaries included in this handbook may constitute a large part of the governing document for the Valero Energy Corporation Retiree Health Care Plans and in some cases may constitute the governing document. Retirees should refer to the following contact information for assistance. Benefit Provider Toll-Free Number Website Aetna Medical (800) (Network: Aetna Choice POSII Open Access) Express Scripts Traditional (800) Prescription Coverage (non- Medicare) Aetna Dental (800) (Network: Dental PPO/PDN with PPOII Network) VSP (vision plan) (800) AmWINS (Retiree Health Care Plan Administration) Valero Retiree Administration Department (877) Monday Friday, 7:00 a.m. to 7:00 p.m. CST (800) extension Life Insurance Claims (800) extension 2283 Introduction 1

9 Benefit Provider COBRA Administration & Health Services Toll-Free Number (401) Website Introduction 2

10 PLAN ADMINISTRATION Upon retirement, the Company offers medical (which includes prescription), dental and vision coverage to retirees. Retirees may also be provided with a company paid life insurance benefit. Effective April 1, 2014, day-to-day administration of the retiree medical, dental, and vision benefits are administered by AmWINS. However, Valero continues to sponsor the retiree health care plans. The Valero Retiree Administration Department continues to administer the retiree life insurance plans. The cost of the coverage is dependent on the group or classification at retirement and the Medicare eligibility of the retiree and any eligible dependents. ELIGIBILITY In order to be eligible for retiree health care coverage, an individual must be 55 years old, have five years of service at the time they terminate employment, and: Be a former employee of the Company who is eligible to retire according to the provisions determined by the Company, or In certain circumstances, be an individual receiving retiree health care coverage under a plan sponsored by an entity that is subsequently acquired by the Company. ELIGIBLE DEPENDENTS A retiree may elect coverage for eligible dependents under the Valero Retiree Health Care Plan. Eligible dependents include: Spouse A certificate of marriage is required. Common Law Spouse A notarized Affidavit of Common Law Marriage is required. A common law spouse may only be added upon retirement or during the Annual Open Enrollment period. To be eligible for coverage, the retiree and the Common Law Spouse (CLS) must certify that they: Are at least 18 years of age and mentally competent to consent to a contract, Live together in the same residence in an exclusive, committed domestic relationship, have done so for a minimum of six months, and intend to do so indefinitely (documentation must reflect cohabitation for at least six months prior to the date coverage is requested), Share joint responsibility for one another s common and financial welfare, and Plan Administration 3

11 Are not in the relationship solely for the purpose of obtaining coverage. Retirees who wish to cover their CLS under the plan must submit: 1. A notarized Affidavit of Common Law Marriage signed by the retiree and the retiree s CLS, 2. A Health Care Agent Agreement or Health Care Power of Attorney, and 3. Two forms of documentation from the following list: Common ownership of real property (joint deed or mortgage agreement) or a common leasehold interest in property, Common ownership of a motor vehicle, Driver s license listing a common address, Proof of joint bank and credit accounts, and/or Proof of designation as a primary beneficiary for life insurance or retirement benefits, or a primary beneficiary designation under a common law spouse s will. If the retiree resides in a state that recognizes common law marriage and the state or locality issues a form of certification of common law marriage, the retiree must obtain and provide: A copy of the certification issued by the state or locality, A copy of the notarized Affidavit of Common Law Marriage, and A copy of at least one of the documents listed from #3 above as supporting a common law marriage. To drop a CLS from the plan upon termination of the common law marriage, the plan terms that govern the treatment of a retiree and spouse upon divorce apply if the retiree resides in a state that recognizes common law marriage. If, however, the common law marriage is not recognized under applicable state law, the retiree must submit a notarized Affidavit of Dissolution of Common Law Marriage acknowledging the relationship has ended. For more information about the Company s Policy for Common Law Marriage or to obtain a copy of either the policy or affidavit, please contact the Valero Retiree Administration Department. Plan Administration 4

12 Same-Sex Spouse A certificate of marriage is required. A same-sex spouse may only be added if married in a state that recognizes same-sex marriage. Domestic Partner/Same-Sex Partner A notarized Affidavit of Domestic Partner Relationship and supporting documentation are required. Opposite sex domestic partners must be common law spouses to be considered eligible for coverage. If residing in a state that recognizes Domestic Partner Relationship, a copy of the state issued certificate is required. For states that do not recognize the unity of a domestic partner marriage, the spouse can only be added during the Annual Open Enrollment period. Children through the end of the month in which they turn age 26 regardless of their eligibility for group coverage through their own employer Children who are the retiree s natural children, stepchildren or legally adopted by the retiree. A birth certificate, Qualified Medical Child Support Order (QMCSO), or proof of adoption or legal guardianship (court appointed) is required. Foster children or other children residing with the retiree in a legal guardian relationship (court appointed) and relying on the retiree for support. Proof of foster care or legal guardianship is required. Foster children or other children where support and coverage are required by a court order. A copy of the court order is required. Children up to any age who were permanently, physically or mentally disabled before age 26 and who have been continuously eligible for coverage, or for whom coverage is requested at Annual Open Enrollment. The dependent must be unable to support themselves, reside with the retiree and depend on the retiree for more than half their support. Proof of permanent disability is required and will be reviewed by the carrier. Newborn children will have coverage retroactive to the date of birth upon proof of birth and timely enrollment in a Valero Retiree Health Care Plan. ELECTIONS AND ENROLLMENT PERIODS Initial Enrollment Period Upon notification of retirement, the benefits department will provide a package containing information about an employee s pension benefit, Thrift 401(k) balances, COBRA continuation of health care plan coverage, and basic information about retiree health care and life insurance. Plan Administration 5

13 AmWINS will be notified immediately so that they can prepare and mail the retiree a health care enrollment kit. The enrollment kit should be returned directly to AmWINS in the envelope they provide. Retirees wishing to enroll in health care benefits under the plan must complete and return the Retiree Enrollment/Direct Payment Authorization Form within 30 days from the date of the enrollment kit from AmWINS. If a retiree does not enroll within this period, they waive all rights to benefits under the plan and are not eligible to enroll at any later date. Participation in the active employee plans will terminate on the last day of the month in which the employee retires. Retiree coverage is effective the first of the month following retirement from Valero. When making plan elections, retirees must choose one plan for all covered members, except in the case of a split household with participants who are both Medicare eligible and non-medicare eligible. For more information, refer to the section in this handbook titled Split Households. Annual Open Enrollment The Company s retiree health care plans are kept on a calendar year basis from January 1 through December 31. In the fall of each year, during the Annual Open Enrollment period, retirees will receive notification of any plan changes or premiums changes for the upcoming plan year. Information about retiree health care premiums will be provided during every Annual Open Enrollment period. Current premium information is also available by calling AmWINS at (877) , Monday through Friday 7 a.m. 7 p.m. (CST), or by visiting the AmWINS website at Special Enrollment Period for Qualified Change Events A retiree may be eligible to add coverage upon experiencing a Qualified Status Change (QSC), or upon receiving a judgment, decree or order (other than a divorce decree), during a special enrollment period. To qualify for a change in coverage, the change must directly affect benefits. An example would be the need to elect retiree and spouse coverage upon marriage. A retiree may reduce or drop coverage at any time. For detailed information about notification and documentation requirements, refer to the section of this handbook titled Qualified Change Events. COVERAGE OPTIONS Available coverage options will be provided in the enrollment kit(s) sent by AmWINS, and differs for Medicare eligible participants and non-medicare eligible participants. Retirees with questions regarding coverage options should contact AmWINS once they have received their enrollment kit(s). Plan Administration 6

14 HEALTH CARE PREMIUMS Retiree health care premiums will be electronically debited from a designated personal bank account on a monthly basis through Automated Clearing House (ACH). Retirees will need to complete the Direct Payment Authorization Form. This form will be distributed in the initial enrollment packet. A new form will not be required each year. Retirees should only submit a new form if there has been a change to their banking information. For questions about ACH, or to request a form, contact AmWINS at (877) , Monday through Friday 7 a.m. 7 p.m. (CST), or visit the AmWINS website at ID CARDS Retirees should present their ID cards to their health care provider when seeking medical, dental or prescription drug services. Medical Plans Non-Medicare Eligible Participants Aetna Retiree Medical and Dental Aetna ID cards will be issued upon enrollment in the plan(s). Participants enrolled in both an Aetna medical plan and the Aetna Retiree Dental $50 Deductible Plan with the same coverage level will receive a combined medical and dental ID card (i.e., retiree only; retiree and spouse; retiree and child; retiree and family). If the elected coverage levels for the plans are different, ID cards for each plan will be issued. Participants will receive up to two cards per household. If needed, participants may request additional or replacement cards from the carrier. Medicare Eligible Participants Medicare eligible participants will receive new ID cards upon their initial enrollment in a Medicare supplement plan. If needed, participants may request additional or replacement cards from AmWINS. ESI Prescription Drug Coverage ID Cards Non-Medicare Eligible Participants If a new participant was previously enrolled in an Aetna or CIGNA medical plan, they will not receive new ESI prescription drug ID cards. If a new participant was previously enrolled in a Kaiser Permanente plan, an initial ESI prescription drug ID card will be issued. If needed, participants may request additional or replacement cards from the carrier. Plan Administration 7

15 Medicare Eligible Participants Medicare eligible participants will receive new ID cards upon their initial enrollment in a Medicare supplement plan. If needed, participants may request additional or replacement cards from the AmWINS. VSP Retiree Vision Plan ID Cards While VSP members are not required to have an ID card to access services, members may visit to register and print an ID card that includes their name, group number and plan design information. WHEN HEALTH CARE COVERAGE ENDS A retiree s coverage ends when/on: The date the retiree voluntarily drops coverage under the retiree health care plan(s), The last day of the month for which premiums were last paid for retiree benefits, if payment is not received within 30 days from the due date, The date a fraudulent claim is made by the retiree or on behalf of the retiree with the retiree s knowledge, The plan(s) is terminated, or The date of the retiree s death. A retiree s covered dependent(s) coverage ends when/on: The date the retiree voluntarily drops coverage under the retiree health care plan(s), The last day of the month for which premiums were last paid for retiree benefits, if payment is not received within 30 days from the due date, The date a fraudulent claim is made by or on behalf of the dependent with the retiree s knowledge, The plan(s) is terminated, The date of the retiree s death (for exception, see the section titled Continuing Coverage After the Death of a Retiree), or Plan Administration 8

16 The date the retiree s dependent(s) no longer meets the eligibility requirements of the plan(s). CONTINUING COVERAGE AFTER THE DEATH OF A RETIREE In the event of the retiree s death, eligible dependents who wish to continue health care coverage must contact AmWINS. Spouses, Common Law Spouses and Domestic Partners may continue their coverage for the plan(s) under which they were covered immediately prior to the retiree s death as a surviving spouse. Eligible dependent children may continue coverage for the plan(s) under which they were covered immediately prior to the retiree s death under: A surviving spouse s coverage, if applicable, or As a primary insured participant in accordance with the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). QUALIFIED CHANGE EVENTS A qualified change event includes, but is not limited to, the following: Marriage, Birth, adoption or placement for adoption of a dependent child, legal guardianship, Divorce, legal separation or annulment, Death of a dependent, Change in the dependent s employment status resulting in a loss or gain of other coverage, and A QMCSO (or similar judgment or decree that affects the health care coverage of the retiree, the retiree s spouse or the retiree s dependent). To qualify for a change in coverage level to existing health care plans, the change must directly affect benefits. Retirees must submit written notification and documentation of the qualified change event to AmWINS within 30 days of the qualified change event, including the ineligibility of a dependent. Required documentation for a qualified change event is as follows: Marriage marriage certificate Birth birth certificate or courtesy hospital copy Plan Administration 9

17 Adoption or Legal Guardianship official court documentation of adoption or guardianship Divorce or Annulment First and last page of final divorce decree signed by the judge, Affidavit of Dissolution of Common Law Marriage, or Affidavit of Dissolution of Domestic Partner Relationship. Death death certificate Change in dependent s employment status resulting in a loss or gain of other coverage A document from the employer indicating the effective date of the gain or loss of other coverage QMCSO (or similar judgment or decree that affects the health care coverage of the retiree, the retiree s spouse or the retiree s dependent) court decree A retiree may also wish to consider a change of beneficiary in the event of a qualified change event. Adding Dependents Where a qualified change event results in a dependent becoming eligible for coverage under the Valero Retiree Health Care Plan, a written request and supporting documentation, as stated in this section, are required within 30 days of the qualifying event. Requests to add new or previously ineligible dependents 30 days after a qualifying event will not be granted. In such cases, the retiree must wait until the Annual Open Enrollment period to add the new dependent(s). To add a new dependent(s), retirees should contact AmWINS at (877) , Monday through Friday 7a.m. 7p.m. (CST), or visit the AmWINS website at Removing Dependents Where a qualified change event results in a dependent losing coverage under the Valero Retiree Health Care Plan, certain dependents may be eligible to continue health care coverage in accordance with the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). For more information, refer to the section of this handbook titled Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA). To remove a dependent(s), retirees should contact AmWINS at (877) , Monday through Friday 7a.m. 7p.m. (CST), or visit the AmWINS website at Plan Administration 10

18 CHANGE IN ADDRESS Address changes must be submitted in writing. The written communication should include the effective date of the address change to ensure that pension checks (if applicable) and correspondence are mailed to the correct address. The Address Change Form may be obtained by calling AmWINS at (877) , Monday through Friday 7a.m. 7p.m. (CST), or by visiting the AmWINS website at BENEFICIARY INFORMATION A beneficiary is a person named to receive benefits in the event of a retiree s death. To name a beneficiary, a Valero Energy Corporation Beneficiary Designation Form (Beneficiary Designation Form) must be completed. The Beneficiary Designation Form must be on file with the Company before a retiree s death to ensure that benefits are paid to the beneficiary of the retiree s choice. Beneficiary Designation Forms completed during active employment remain in force during the retiree s lifetime unless an updated form is submitted. To obtain a Beneficiary Designation Form, retirees should contact AmWINS at (877) , Monday through Friday 7a.m. 7p.m. (CST), or visit the AmWINS website at In the absence of a Beneficiary Designation Form, survivor benefits will be paid as outlined in the plan documents. A contingent beneficiary is explained on the Beneficiary Designation Form. A retiree may change beneficiary designations for all life insurance plans at any time. If a retiree s beneficiary dies within 30 days of the retiree s death, benefits are paid to a contingent beneficiary (or beneficiaries). MEDICARE ELIGIBILITY AND THE VALERO RETIREE HEALTH CARE PLANS The Valero Retiree Health Care Plans require that participants who are Medicare eligible due to age or disability be enrolled in Medicare Part A and Part B. Participants enrolling in a Medicare supplement plan through AmWINS will be automatically enrolled in the Valero sponsored Medicare Part D Prescription Drug Program. When making plan elections, retirees must choose one plan for all covered members, except in the case of a split Medicare eligible and non-medicare eligible household. For more information, please refer to the section in this handbook titled Split Households. Participants must have an address within the domestic United States to be eligible for the Medicare supplement plans offered through AmWINS. For additional information, please contact AmWINS at (877) , Monday through Friday 7a.m. 7p.m. (CST), or visit the AmWINS website at Plan Administration 11

19 Medicare Eligible at Retirement Retirees and their covered dependents who will be Medicare eligible on their retirement date should enroll in Medicare Part A and Part B on the first of the month after their retirement date. To enroll in Medicare, eligible participants should contact the Social Security Administration Office at (800) Becoming Medicare Eligible During Retirement Participants who are no longer eligible for the Non-Medicare Valero sponsored plans will be disenrolled the last day of the month prior to their Medicare eligibility. If other members of the household are currently enrolled in a non-medicare plan, they will remain enrolled as long as they are not Medicare eligible and pay applicable premiums. If a retiree or a covered dependent becomes Medicare eligible due to a disability, they must notify AmWINS immediately and enroll in Medicare Part A and Part B. AmWINS will then send an enrollment kit containing information about the Valero sponsored Medicare supplement plans. Participants enrolling in a Medicare supplement plan will be automatically enrolled in the Valero sponsored Medicare Part D Prescription Drug Program. Retirees and their covered dependents who become Medicare eligible due to age will be notified by AmWINS up to three months prior to turning age 65. Participants will receive an enrollment kit containing information about the Valero sponsored Medicare supplement plans. Participants enrolling in a Medicare supplement plan will be automatically enrolled in the Valero sponsored Medicare Part D Prescription Drug Program. Split Households A split household contains both non-medicare and Medicare eligible participants. A split household will be sent one enrollment kit for a plan election for all non-medicare eligible participants and one enrollment kit for a plan election for all Medicare eligible participants. QUALIFIED MEDICAL CHILD SUPPORT ORDERS (QMCSOs) All medical, dental and vision plans are required by law to administer benefits in accordance with a QMCSO. For more information regarding QMCSOs, refer to the section titled Qualified Change Events. Plan Administration 12

20 VALERO SPONSORED RETIREE HEALTH CARE PLANS Employees Hired Prior to January 1, 2010 Valero sponsors retiree health care plans for both non-medicare and Medicare eligible participants. VALERO SPONSORED NON-MEDICARE PLANS Retirees and their dependents, who are not eligible for Medicare, are offered an option of either the Aetna Retiree Medical $1,000 Deductible Plan (Deductible Plan) or the Aetna Retiree PPO Plan (PPO Plan). The following benefits apply to retirees and their eligible dependents who have elected coverage through either the Deductible Plan or the PPO Plan. DEDUCTIBLE PLAN The Deductible Plan helps pay for a wide range of medical expenses for the treatment of non work-related illness or injury, as well as certain preventive benefits. Payment in the Deductible Plan will not be considered until treatment is rendered. Participants will receive an Aetna ID card that should be presented to the provider at the time of service. Providers are encouraged to file claims electronically. Providers should call Aetna at (888) for coverage inquiries prior to services being rendered. The grid below summarizes the deductibles and out-of-pocket maximums for the Deductible Plan. For information about covered services and supplies, refer to the section of this handbook titled What is Covered Under the Deductible Plan and PPO Plan. For more detailed information on plan coverage, contact Aetna at (800) Plan Provision Individual calendar year deductible (network & out-ofnetwork) Individual out-of-pocket maximum Family out-of-pocket maximum Individual lifetime maximum Subject to: Network and out-of-network benefit provisions Precertification provisions Coordination of Benefits with other medical plans Network/Out-of-Network $1,000 $2,500/$5,000 $5,000/$10,000 $2,000,000 Yes Yes Yes DEDUCTIBLE PLAN SCHEDULE OF BENEFITS Please refer to Exhibit A at the end of this handbook for a copy of the Deductible Plan Benefits Summary. Deductible Plan 13

21 PPO PLAN The PPO Plan helps pay for a wide range of medical expenses for the treatment of non work-related illness or injury, as well as certain preventive benefits. This is a highlight of benefits, and is not all inclusive of plan benefits, services, limitations or exclusions. All medically necessary services are subject to plan provisions in effect at the time services are rendered. The PPO Plan and network providers have agreed upon negotiated charges for certain services and supplies. Negotiated charge means the maximum charge a network provider has agreed to make for any service or supply for the purpose of the benefits under the PPO Plan. Refer to for network provider information (network: Aetna Choice POSII Open Access). The grid below summarizes the benefit provisions of the PPO Plan. For information about covered services and supplies refer to the section of this handbook titled What is Covered Under the Deductible Plan and PPO Plan. For more detailed information on plan coverage, contact Aetna at (800) Plan Provision Individual calendar year deductible Family deductible Individual out-of-pocket maximum Family out-of-pocket maximum Individual lifetime maximum Doctor visit copayment Specialist visit copayment Urgent care services copayment Emergency room services copayment Subject to: Network and Out-of-network benefit provisions Precertification provisions Coordination of Benefits with other medical plans Network/Out-of-Network $500/$1,000 $1,000/$2,000 $2,500/$5,000 $5,000/$10,000 $2,000,000 $25 (network only) $35 (network only) $100 (network only) $200/$200 Yes Yes Yes Each participant: Chooses whether to receive network or out-of-network services, Pays any required copayment for network or out-of-network services, Pays any required deductible for network or out-of-network services, Pays any required coinsurance amount for network or out-of-network services, and Will file a claim form to be reimbursed for out-of-network services. PPO Plan 14

22 Participants will receive an Aetna ID card that should be presented to the provider at the time of service. Providers are encouraged to file claims electronically. Providers should call Aetna at (888) for coverage inquiries prior to services being rendered. PPO PLAN ROUTINE HEARING BENEFIT Hearing services are included in the PPO Plan. Hearing exams obtained through a network provider are covered at 100% after a $35 office visit copayment. Hearing aids (hardware) are eligible for a maximum annual benefit of $150. A participant must submit a medical claim form and supporting receipt(s) to Aetna for reimbursement of hardware expenses (and an exam expense from an out-of-network provider). Claims should be mailed to: Aetna P.O. Box El Paso, Texas Participants may obtain a claim form on the Aetna website at PPO PLAN SCHEDULE OF BENEFITS Please refer to Exhibit B at the end of this handbook for a copy of the PPO Plan Benefits Summary. PPO Plan 15

23 HOW THE DEDUCTIBLE AND PPO PLANS WORK The following provisions apply to Deductible and PPO Plan expenses. Deductibles The deductible is the amount a participant pays for covered expenses each year before the plan begins to pay. For participants who are subject to network and out-of-network benefit provisions, any amounts paid toward network or out-of-network expenses will be applied to the individual network and out-of-network calendar year deductibles. Deductible at Year End If an eligible participant is confined in a covered hospital or facility for a period of time extending past January 1 of any calendar year, a new individual calendar year deductible amount will be required of such individual for the charges incurred in the new calendar year during that confinement. Deductible for Newborns The deductible is waived for the inpatient facility nursery expenses for the newborn. This deductible waiver applies to the facility charges only. The newborn will be charged the applicable deductible for any individual physician's or ancillary charges incurred while the newborn is inpatient. Deductible for Preventive Services No deductible is required for preventive services. Immunizations No deductible is required for immunizations (including routine and travel immunizations and flu shots). Payment Percentage The payment percentage is the percentage of covered expenses the plan pays and the percentage of covered expenses the participant will pay. Once applicable deductibles have been met, the plan will pay a percentage of the covered expenses, and the participant will be responsible for the remainder of the costs. For participants who are subject to network and out-of-network benefit provisions, the payment percentage may vary by type of expense and whether or not the participant uses a network or out-ofnetwork provider. Participants should refer to the Deductible and PPO Plan Benefits Summaries at the end of this handbook for a detailed listing of payment percentage amounts for each covered benefit. Out-of-Pocket Maximums Individual Out-of-Pocket Maximum The individual network or out-of-network out-ofpocket maximum is the largest amount of out-of-pocket expenses a participant would pay in one calendar year for network or out-of-network expenses. It includes the individual calendar year deductible and the participant s co-insurance share of covered medical network or out-of-network expenses. Once the network individual out-of-pocket How the Deductible and PPO Plans Work 16

24 maximum is reached, the Deductible and PPO Plans pay 100% of the covered network expenses for the remainder of that calendar year. Once the out-of-network individual out-of-pocket maximum is reached, the Deductible and PPO Plans pay 100% of covered out-of network expenses for the remainder of that calendar year. Family Out-of-Pocket Maximum A family network or out-of-network out-of-pocket maximum applies if a participant covers themselves and children, or themselves and family (spouse and children). Once a participant and family have reached the family network out-of-pocket maximum, the Deductible and PPO Plans pay 100% of the covered network expenses for all covered individuals for the remainder of that calendar year. Once a participant and family have reached the family out-of-network out-ofpocket maximum, the Deductible and PPO Plans pay 100% of the covered out-ofnetwork expenses for all covered individuals for the remainder of that calendar year. Exclusions Certain expenses do not apply toward the network or out-of-network out-of-pocket maximums. These include, but are not limited to: Charges over the recognized charge, Non-covered expenses, Expenses from non-emergency use of the emergency room, or Penalties for out-of-network expenses that required precertification, but precertification was not obtained from Aetna. Lifetime Maximum Benefit The lifetime maximum benefit is the most the plan will pay for covered expenses incurred by any one covered participant during their lifetime. The lifetime maximum benefit for participants is $2,000,000 and applies to network and out-of-network expenses combined. If a participant has met their lifetime maximum benefit, there is an automatic yearly restoration benefit at the beginning of each new benefit period. This restoration will restore expenses paid by the plan up to a maximum of $20,000 per year without action on the participant s part. Evidence of good health will not be required. However, the participant s coverage must be in force in order for restoration of benefits to apply. Networks The Deductible and PPO Plans provide access to covered benefits through a network of health care providers and facilities. These network providers have contracted with Aetna, an affiliate or third party vendor, to provide health care services and supplies to How the Deductible and PPO Plans Work 17

25 Aetna plan members at a reduced fee called the negotiated charge. The network utilized for the Deductible and PPO Plan is called the Aetna Choice POS II Open Access network. The Aetna Choice POS II Open Access network is designed to lower out-of-pocket costs when participants use network providers for covered expenses. Deductibles and co-insurance will generally be lower when using participating network providers and facilities. Refer to for network provider information. Participants also have the choice to access licensed providers, hospitals and facilities outside the network for covered benefits. Out-of-pocket costs (deductibles and coinsurance) will generally be higher when participants utilize out-of-network providers. Out-of-network providers have not agreed to accept the negotiated charge and may balance bill the participant for charges over the recognized charges. The recognized charge is the maximum amount Aetna will pay for a covered expense from an out-ofnetwork provider. Out-of-pocket costs may vary between network and out-of-network benefits. Participants should refer to the Deductible and PPO Plan Benefits Summaries at the end of this handbook to understand the cost sharing charges. Availability of Providers Aetna cannot guarantee the availability or continued participation of a particular network provider. Either Aetna or any network provider may terminate the provider contract or limit the number of patients accepted in a practice. Pre-existing Conditions The Deductible and PPO Plans do not contain a pre-existing condition clause. In the event a participant becomes eligible for another plan that does contain pre-existing condition exclusions, federal law limits the circumstances under which coverage may be excluded for medical conditions present before enrolling. Precertification Precertification is a process that helps the participant and the participant s physician determine whether the services being recommended are covered expenses under the Deductible and PPO Plan. It also allows Aetna to help the participant s provider coordinate transition from an inpatient setting to an outpatient setting (called discharge planning), and to register for specialized programs or case management when appropriate. A participant does not need to precertify services provided by a network provider. Network providers are responsible for obtaining the necessary precertification. Since precertification is the provider s responsibility, there is no additional out-of-pocket cost to the participant as a result of a network provider s failure to precertify services. How the Deductible and PPO Plans Work 18

26 When a participant goes to an out-of-network provider, it is the participant s responsibility to obtain precertification from Aetna for any services or supplies on the precertification list below. A participant s provider may precertify the participant s treatment; however the participant should verify with Aetna prior to the procedure, that the provider has obtained precertification from Aetna. If the service or supply is not precertified by the participant or the participant s provider, the participant s benefits may be significantly reduced or expenses may not be covered by the plan. To precertify an admission or one of the following outpatient services, participants should call Aetna at (800) Providers should call Aetna at (888) and select option 3. Precertification is required for the following types of medical Inpatient and Outpatient Care expenses: Stays in a hospital; Stays in a skilled nursing facility; Stays in a rehabilitation facility; Stays in a hospice facility; Outpatient hospice care; Stays in a Residential Treatment Facility for treatment of mental disorders and substance abuse; Partial Hospitalization Programs for mental disorders and substance abuse; Home health care; Private duty nursing care; Intensive Outpatient Programs for mental disorders and substance abuse; Amytal interview; Applied Behavioral Analysis; Biofeedback; Electroconvulsive therapy; Neuropsychological testing; How the Deductible and PPO Plans Work 19

27 Outpatient detoxification; Psychiatric home care services; Psychological testing. The Precertification Process for Out-of-Network Admissions or Services The participant or a member of the participant s family, a hospital staff member or the attending physician must contact Aetna to precertify the following out-of-network admissions or services within the following timelines: Out-of-Network Admission or Service For non-emergency admissions (including hospitalizations, skilled nursing facilities, hospice, home health care, ambulatory surgical facilities and rehabilitation/treatment facilities) For an emergency admission For an urgent admission Responsible Party for Precertification The participant, the participant s physician or the facility must call and request precertification at least 14 days before the scheduled admission date. The participant, the participant s physician or the facility must call within 48 hours or as soon as reasonably possible after the participant has been admitted. The participant, the participant s physician or the facility must call before the participant is scheduled to be admitted. An urgent admission is a hospital admission by a physician due to the onset of or change in an illness; the diagnosis of an illness; or an injury. Aetna will provide a written notification to the participant and the participant s physician of the precertification decision. If the precertified expenses are approved, the approval is generally good for 60 days as long as the participant remains enrolled in the plan. When the participant has an inpatient admission to a facility, Aetna will notify the participant, the participant s physician and the facility of the precertified length of stay. If the participant s physician recommends the stay be extended, additional days must be certified. The participant, the participant s physician or the facility must call Aetna at the number on the participant s ID card as soon as reasonably possible, but no later than the final authorized day. Aetna will review and process the request for an extended stay. The participant and the participant s physician will receive a notification of an approval or denial. If precertification determines the stay or services and supplies are not covered expenses, the notification will explain why and how Aetna s decision can be appealed. The participant and/or the participant s provider may request a review of the How the Deductible and PPO Plans Work 20

28 precertification decision according to the section of this handbook titled Aetna Claims and Appeals. How Failure to Precertify Affects Benefits A precertification benefit reduction will be applied to the benefits paid if a participant fails to obtain required precertification prior to incurring medical expenses. This means Aetna will reduce the amount paid towards coverage or expenses may not be covered. A $200 benefit reduction will be applied separately to certain designated procedures covered under the outpatient precertification program for failure to precertify. The participant will be responsible for the unpaid balance of the bills. The chart below illustrates the effect on benefits if necessary precertification for outpatient or inpatient services, procedures and treatments is not obtained. If Precertification is: Requested and approved by Aetna Requested and denied Not requested, but would have been covered if requested Not requested, and would not have been covered if requested Then the Expenses are: Covered. Not covered, and may be appealed. Covered after a precertification benefit reduction is applied. Not covered, and may be appealed. It is important to remember that any additional out-of-pocket expenses incurred because the participant s precertification requirement was not met will not count toward the participant s deductible, payment percentage or maximum out-of-pocket limit. Emergency and Urgent Care Emergency and urgent care coverage is available 24 hours a day, seven days a week, anywhere inside or outside the plan s service area for: An emergency medical condition, or An urgent condition. In Case of a Medical Emergency An emergency medical condition is a recent and severe condition, sickness or injury, including (but not limited to) severe pain, which would lead a prudent layperson (including the parent or guardian of a minor child or the guardian of a disabled individual) possessing an average knowledge of medicine and health to believe that failure to get immediate medical care could result in: How the Deductible and PPO Plans Work 21

29 Placing a participant s health in serious jeopardy, Serious impairment to a bodily function(s), Serious dysfunction to a body part(s) or organ(s), or In the case of a pregnant woman, serious jeopardy to the health of the unborn child. When emergency care is necessary, participants should follow the guidelines below: Seek the nearest emergency room, or dial 911 or a local emergency response service for medical and ambulatory assistance. If possible, call the participant s physician provided a delay would not be detrimental to the participant s health. After assessing and stabilizing the participant s condition, the emergency room should contact the participant s physician to obtain the participant s medical history to assist the emergency physician in the participant s treatment. If the participant is admitted to an inpatient facility, notify the participant s physician as soon as reasonably possible. If a participant seeks care in an emergency room for a non-emergency condition (one that does not meet the criteria above), the plan will not cover any incurred expenses. In Case of an Urgent Condition An urgent condition is a sudden illness, injury or condition that: Requires prompt medical attention to avoid serious deterioration of the participant s health, Cannot be adequately managed without urgent care or treatment, Does not require the level of care provided in a hospital emergency room, and Requires immediate outpatient medical care that cannot wait for the participant s physician to become available. Call the participant s physician if urgent care is needed. Physicians usually provide coverage 24 hours a day, including weekends and holidays for urgent care. The participant may contact any physician or urgent care provider for an urgent care condition if the participant cannot reach the participant s physician. How the Deductible and PPO Plans Work 22

30 If it is not feasible to contact their physician, the participant should do so as soon as possible after urgent care is provided. If the participant needs help finding an urgent care provider they may call Aetna at (800) or access Aetna s online provider directory at Follow-up care after treatment of an emergency or urgent medical condition is not considered an emergency or urgent condition and is not covered as part of any emergency or urgent care visit. Once the participant has been treated and discharged, the participant should contact the participant s physician for any necessary follow-up care. Follow-up care includes (but is not limited to) suture removal, cast removal and radiological tests such as x-rays. For coverage purposes, follow-up care is treated as any other expense for illness or injury. If the participant accesses a hospital emergency room for follow-up care, the participant s expenses will not be covered and the participant will be responsible for the entire cost of treatment. To keep out-of-pocket costs lower, follow-up care should be provided by a physician within an office setting. For participants who are subject to network and out-of-network benefit provisions, a participant may use an out-of-network provider for follow-up care. The participant will be subject to the deductible and coinsurance that apply to out-of-network expenses, which may result in higher out-of-pocket costs. How the Deductible and PPO Plans Work 23

31 HOW MEDICAL EXPENSES ARE PAID THROUGH THE DEDUCTIBLE AND PPO PLANS In most cases, the physician or health care provider will file a claim on the participant s behalf. Providers can submit claims electronically. When it is necessary for a retiree to file a claim for medical benefits, forms are available on Aetna s website at Medical claims should be filed promptly when expenses are incurred. The completed form should be sent directly to the address shown on the back of the Aetna ID card. Instructions on the claim form should be followed carefully, making sure all questions are answered and all required medical statements and itemized bills are turned in with the form. Separate claim forms should be filed for each family member. Copies of claims and all bills submitted should be retained for the participant s records. All claims should be filed promptly. The claim filing deadline for the Deductible and PPO Plan is 24 months from the date of service. The claim will be processed and an EOB sent to the participant, the physician and any other provider of care. If the claim is denied, the participant has the right to appeal. For complete information on filing and appealing claims, refer to the section of this handbook titled Aetna Claims and Appeals. Covered participants who have medical expenses incurred as a result of an accident and paid by the Deductible or PPO Plan but reimbursed by a third party insurance are required to refund the plan up to the amount the plan paid on the accident. For more information on subrogation and reimbursement, refer to the section of this handbook titled The Right of Subrogation and Reimbursement. How Medical Expenses are Paid Through the Deductible and PPO Plans 24